Additional Info and Signature Form

Additional Info and Signature Form

Returning Participants

(Full Application Not Required)

Thank you for your continued interest in MGH Aspire. There are 2 ways to complete the application: you may download the application forms and enter your responses electronicallyor you may print the forms and enter handwritten responses.

A complete application includes:

☐ / Program Interest Sheet(separate document)
☐ / Additional Info and Signature Formfor Returning Participants (p 2)
☐ / New or updated relevant information (e.g., evaluations, behavior plans, IEP, 504, etc.)
☐ / Updated Releases of Information (as applicable)
*Applicants 18 years and older need to submit releases for parent/guardian communication to occur.

Please Submit Your Application and Payment via:

Email /
Phone / 781-860-1900
Fax / 781-860-1920
Mail / MGH Aspire
1 Maguire Road
Lexington, Massachusetts 02421
Aspire accepts checks payable toMGH Aspire and sent to the address above or a credit card over the phone at 781.860.1900.
You will receive a confirmation email within 5 business days of Aspire receiving your application.Applications are accepted on a rolling basis until programs are full. Candidates will be scheduled for an interview sessionat our Lexington office upon receipt of the complete application packet. These interview sessions are designed to match applicants to peer groups; our goal is to determine the best placement for your child.
Please contact us at 781-860-1900 or email us at if you have any questions.
Copies of background check procedures, healthcare and discipline policies are available upon request.

Financial assistance is awarded based on financial need and fund availability.

The financial aid application can be downloaded from our website.

Thank you for applying to the MGH Aspire program!

Additional Info and Signature Forme

First and Last Name: / MGH MRN:
Additional Information
Is there any new information about the applicant you would like us to know?
Application Signatures
To the best of my knowledge, I have providedall relevant information in this application.
Applicant Signature (if applicant is 18 years or older) / Date:
Legal Guardian Signature (if applicable) / Date:
Legal Guardian Signature (if applicable) / Date:

Person responsible for payment and billing:

Signature (if not provided above)
Name/Relationship: / Date:

A note on insurance:

Please be aware that Aspire offers multidisciplinary interventions that do not fit standard medical procedure codes; therefore, our services are not reimbursable by medical insurers.

☐ Yes - I plan to submit a financial aid application.

☐ Yes - add me to the Aspire Wire (electronic newsletter) at the following email address:
☐ Yes - add me to the Lurie Center Research electronic newsletter at the following email address:

“Unencrypted” Email preference (optional):

The Partners standard is to send email securely. If you prefer, we can send you "unencrypted" email that is not secure and could result in the unauthorized use or disclosure of your information. If you want to receive communications by unencrypted email despite these risks, Partners HealthCare will not be held responsible. Your preference to receive unencrypted email will apply to Aspire communications.

By signing below, I am authorizing Aspire staff to communicate via unencrypted email with me.

Signature / Email:
Signature / Email:

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1 Maguire Road, Lexington, MA 02421 | Tel 781-860-1900 | Fax 781-860-1920 |